Hemorrhoidectomy

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Overview

Hemorrhoids are enlarged or dilated veins located in and around the rectum and anus. There are two types: external and internal. External hemorrhoids occur below the anal sphincter and protrude at the anus. Thrombosed hemorrhoids contain clotted blood and can cause pain. Thrombosis usually occurs in external hemorrhoids but does occur in both types. Thrombosed external hemorrhoids can be incised and the clot evacuated.

Internal hemorrhoids occur above the anal sphincter and are classified as first-degree, second-degree, third-degree, and fourth-degree. First- and second-degree hemorrhoids may bleed with defecation, and second-degree hemorrhoids protrude with defecation but return once

the patient stops straining. Third- and fourth-degree internal hemorrhoids may become enlarged and drop down (prolapse) through the anus. Third-degree hemorrhoids protrude with straining and can be pushed back through the anus manually. Fourth-degree cannot be managed manually and may be thrombosed.

Surgical removal of hemorrhoids (hemorrhoidectomy) is recommended for third- and fourth-degree internal hemorrhoids (with or without external hemorrhoids) when conservative treatment measures fail to alleviate severe burning, itching, swelling, protrusion, bleeding, and pain. It is also recommended for external hemorrhoids when medical treatment has failed and symptoms persist.

Hemorrhoidectomy may be performed under general anesthesia (the patient is rendered unconscious), under spinal anesthesia (the patient is numbed from the waist down), or under local anesthesia (the immediate area is injected with a numbing agent similar to that used at the dentist's office). The choice of anesthesia depends on the extent of surgery, the patient's health and personal preference, and surgical standards of the facility.

The patient lies on the operating table face down with the buttocks slightly elevated or on their back with their legs up in stirrups, so the anus and rectal area are exposed. After the anesthesia has taken effect, the area is cleaned with an antiseptic solution. The hemorrhoids are clamped, tied off, and cut away. The wound is then sutured. After the operation, the surgeon packs the anus with gauze or applies antibiotic ointment. A hemorrhoidectomy takes about 1 to 1 1/2 hours to perform.

Newer methods for hemorrhoid removal are being used. One method involves using an ultrasonic scalpel to cut away hemorrhoids. This method is quicker and does not require sutures. Another innovation is the stapled hemorrhoidectomy, in which tissue from further in the anus is used to close the wound with surgical staples after the hemorrhoids are removed. Patients may recover faster and have less postoperative pain, but some research has shown an increase in complications with this procedure.

Preoperative tests may include blood and urine tests, a chest x-ray, and an EKG, depending on the patient's health. These tests are normally done a few days prior to surgery.

Medications that "thin" the blood, including aspirin, are usually discontinued before a scheduled surgery. Some drugs, such as the prescription medication Coumadin® (warfarin), usually must be withheld at least 3 or 4 days prior to a surgical procedure to avoid excessive bleeding during the surgery.

If general anesthesia is going to be used, nothing may be eaten from midnight on the evening before surgery until the procedure is completed. This includes food, water, chewing gum, and candy. This necessary precaution decreases the possibility of vomiting during and after surgery.

For local and spinal anesthesia, dietary restrictions vary. The surgeon may require patients to abstain from eating after midnight, and that should be clarified in advance.

Hemorrhoidectomies are performed in a hospital or outpatient surgery center. Some patients

go home the same day and others remain in the hospital. Check-in is usually the same day as the surgery and at this time an informed consent form must be signed. This is a legal document acknowledging that the patient understands the procedure and its potential risks, and is aware of the medications they will receive.

The anesthesiologist (doctor who administers the anesthesia) performs a brief physical examination and obtains a patient history. It is important that the anesthesiologist is aware of all medications that the patient is taking, any allergies, and any prior adverse reaction to anesthesia. This information helps the anesthesiologist select the most suitable anesthetic agents and dosage and avoid possible complications.

Two to 4 hours before surgery, a mild laxative or enema may be ordered to clear out stool. A sedative also may be administered in the patient's room or in an area designed for patients who are about to undergo surgery. The sedative helps the patient relax and induces drowsiness. Sometimes it is given as an injection about an hour before the surgery, and sometimes it is given intravenously.

All patients have an intravenous line (IV) to administer fluid and medication before, during, and after surgery. The intravenous may be started in the hospital room or in the preoperative area. Anesthesia is given in the operating room.

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